Fractures general management

A high velocity injury should always be treated according to the Advanced Trauma Life Support (ATLS) guidelines with attention to Airway, Breathing and Circulation on presentation. The patient should be optimally resuscitated before any fracture treatment is considered. The basic principles of fracture treatment are appropriate reduction, immobilization and early rehabilitation.

Conservative treatment Most undisplaced or minimally displaced fractures can be satisfactorily treated non- operatively either with plaster immobilization (e.g. ankle fractures), slings (elbow and shoulder fractures), strapping (e.g. phalangeal fractures) and traction (e.g. paediatric femoral shaft fractures).

Closed reduction is usually achieved with manipulation under anaesthetic or intravenous sedation. The injured limb can be immobilized in a plaster, if the fracture displacement has satisfactorily been reduced. Most displaced distal radius fractures (e.g. Colles’ fractures) are treated in this way.

Significantly displaced fractures, however, may require reduction before immobilization.

Traction The aim is to apply an axial pull at the fracture site in order to keep the fractured fragments in a reasonable alignment by appropriate muscle contraction. This can be achieved with ‘skin traction’ (e.g. Femoral fractures in children) or ‘skeletal traction’ (e.g.Tibial traction for neck of femur fracture).

Skin traction involves application of a sustained pull on the limb through weights suspended from a special bandage (tape or kit) applied to the skin. In skeletal traction, a pin (e.g. Steinman’s ) is inserted into the bone and traction is applied by weights through a mechanism of pulleys. This traction may be fi xed (pull against a fi xed point) or sliding (pull against an opposing force, usually body weight).

Other common methods of immobilization are: Collar and cuff sling for shoulder and arm fractures ‘Neighbour’ or ‘buddy’ strapping for phalangeal and metacarpal fractures Commercial splints, e.g. Thomas wrist splints Cast bracing, e.g. tibial plateau fractures

Plaster immobilization may be discontinued after 4 to 6 weeks in the upper limb and 10 to 12 weeks in the lower limb, if clinical and radiological signs of union are present. Paediatric fractures need much shorter periods of immobilization. For example, a young child with a distal radius fracture may show signs of fracture healing as early as 3 weeks and, therefore prolonged immobilization is unnecessary.

Examples of fractures commonly treated with immobilization: Minimally displaced fractures of the proximal humerus Undisplaced fractures of the distal radius Stable compression fractures of the dorsolumbar spine.

Operative treatment Operative treatment should never make the patient worse! Both the surgeon and the patient should be aware of the risks (infection, stiffness, nerve or vessel damage, anaesthetic complications, etc.) associated with operative intervention.

Operative treatment Common indications for operative stabilization of a fracture include: Failure of conservative treatment Early mobilization in order to prevent complications like chest infection, bed sores, etc. Open fractures Polytrauma Associated vascular injury requiring exploration Displaced intra-articular fractures. Fractures of necessity; always fixed.

Fracture of necessity; Some fracture in adults always fixed and not treated conservatively. Neck of Femur fracture, Montagia fracture, Galleazi fracture, Capitulum fracture, Talus fracure.

Operative treatment The principles of open reduction and internal fi xation of fractures are as follows: Anatomical reduction Rigid internal fi xation Early rehabilitation.

Operative treatment Various internal fi xation devices are available. Plates/screws/pins: displaced fractures of the shafts of radius and ulna displaced intra-articular fractures of the tibial plateau may require compression with plates and screws.

Screw fixation; unicondylar fr tibial pleatu, AC Joint dislocation

Scaphoid fr, neck of femur fr. Intra capsular In young

Plates ; anatomical

DHS Extracapsular femoral neck fractures are often treated with a dynamic hip screw This is a specially designed sliding device that provides compression of the fracture site with weightbearing. It permits early mobilization of elderly patients, thus reducing the incidence of serious complications like pneumonia, urinary tract infections, etc.

DHS

HEMI – ARTHROPLASTY unipolar and bipolar

Intramedullary nails: These are metallic implants, which are inserted into the medullary cavities of the long bones for fracture stabilization. Displaced fractures of the shafts of the femur and tibia are commonly treated with such devices. Ideally, an intramedullary nail should be locked proximally and distally with interlocking screws in order toachieve rotational and axial stability. Important complications of intramedullary fi xation include infection, fat embolism, delayed or non-union, joint stiffness, etc.

Russel – taylor nail; short nail; recon nail

External fixator: An external fi xator is an external frame with multiple pins that are inserted into the bone in order to achieve stability. The pins are supported with clamps and rods to stabilize the fracture. Nowadays, various modi fi cations of these frames (e.g. Illizarov’s ring fi xator) are available.

AO fixator ILIZROV fixator

Operative treatment Indications for external fi xation include: Open tibial fractures, especially those associated with bone loss Severely comminuted fractures of the radius Non-union requiring bone transport.

Operative treatment Important complications associated with the use of external fi xators are pin tract infection, joint stiffness, malunion and non-union.

K-wires: Smooth K-wires may occasionally be used for percutaneous fi xation of certain fractures. However, it should be remembered that the use of these wires may cause pin-tract infection, wire migration, nerve damage, etc.

K-wire with external fixator and alone